0022-5347199/1616-1813/0 THE JuC'HNAI. OF ~ R l l l . O < ; Y

Copyright 0 1999 by AhlERlCAN UHOLOGICAL. ASSOCIATION, INC. Vol. 161, 1813-1816. June 1999

Printed in U.S.A.

ANTEGRADE CONTINENCE ENEMA FOR THE TREATMENT OF FECAL INCONTINENCE IN ADULTS: USE OF GASTRIC TUBE FOR CATHETERIZABLE ACCESS TO THE DESCENDING COLON

R. GRADY BRUCE, RIZK E. S. EL-GALLEY, JUDY WELLS AND NIAL T. M. GALLOWAY From the Department of Urology, Emory University School of Medicine and The Emory Continence Center, Atlanta, Georgia

ABSTRACT

Purpose: We describe the use of a gastric segment in performing the antegrade continence enema procedure in patients with refractory fecal incontinence.

Materials and Methods: The antegrade continence enema procedure was performed in 4 women and 3 men with refractory neurogenic fecal incontinence. Preoperative evaluation in- cluded defecography and anorectal manometry. Operative technique involves tunneling a 10 cm. segment of tubularized stomach isolated along the greater curve with preservation of the right gastroepiploic vessels through the anterior tenia of the colon just distal to the splenic flexure. After the stoma is mature the patient passes a catheter and runs 1 to 2 1. warm tap water through it while seated on the toilet. Digital stimulation may be required to initiate bowel emptying and irrigation is continued until clear.

Results: Creation of a nonreflwing catheterizable gastric tube to the descending colon was successful in all 7 patients. At a mean postoperative followup of 22.4 months all patients are continent and use antegrade continence enema irrigation every other day on average. One patient required early revision because of stoma1 stenosis. Special measures include application of a generic antacid tablet to the stoma and use of a skin barrier.

Conclusions: Catheterizable access to the descending colon for the antegrade continence enema procedure more closely approximates normal defecation patterns by emptying ("unloading") the left side of the colon. The stomach is a suitable option in close proximity for this purpose and is especially advantageous when the appendix is not available. The antegrade continence enema procedure using a gastric segment can be safely and effectively performed, and is well suited for use by reconstructive surgeons who are familiar with the Mitrofanoff principle.

KEY WORDS: fecal incontinence, enema, stomach, reconstruction, stoma

Patients with neurological sequelae frequently have neu- rogenic bowel dysfunction in addition to neurogenic bladder problems. Subsequent alterations in bowel related function include alternating diarrhea and constipation, which fre- quently lead to fecal soiling. In addition, these individuals often have associated acquired or congenital pelvic floor dis- orders which impair anorectal sphincter function, and exac- erbate fecal incontinence and constipation. Conservative treatment of such problems includes dietary changes, digital stimulation, rectal suppositories and enemas to initiate co- lonic emptying.

Expanding on the concept introduced by Mitrofanoff,' Malone et a1 introduced the antegrade colonic enema proce- dure as a surgical means for providing antegrade large bowel washouts, thereby promoting fecal continence.2 They origi- nally described using a reversed submucosal tunneled appen- dicocecostomy to provide irrigation to the entire length of the large bowel. Cecal irrigation requires the patient to be supine and roll from side to side for complete evacuation. While this maneuver is effective, the normal pattern of defecation usu- ally only empties the descending colon, sigmoid and rectum. In addition, the appendix may not be available or suitable for use in adults, and other forms of conduit construction must be considered. Stomach has been previously described as an alternate intestinal segment that serves well as a catheter- izable conduit and stoma.3 We describe our experience using a tubularized gastric segment to the descending colon for the antegrade continence enema procedure which more closely approximates normal defecation patterns in adults.

Accepted for publication January 15, 1999.

MATERIALS AND METHODS

From October 1995 through September 1998,4 women and 3 men with refractory neurogenic fecal incontinence were treated with the gastric antegrade continence enema procedure. Aver- age patient age at surgery was 33.6 years (range 23 to 54). Causes of fecal incontinence included myelomeningocele in 5 cases, multiple sclerosis in 1 and post-sacral rhizotomies for pelvic pain in 1. All patients had evidence of bilateral sacral neurogenic deficits and all conservative previous bowel treat- ments had failed. Preoperative evaluation included video de- fecography and anorectal manometry. Concomitant urinary re- construction had previously been performed in all patients, and included ileal augmentation cystoplasty in 5, continent cutane- ous urinary diversion in 1 and ileal conduit in 1 (see table). No patient had an appendix available for the antegrade continence enema conduit, as appendectomy had been performed previ- ously in 3 and was used as the urinary catheterizable conduit (Mitrofanoff) in 4 (see table).

After mobilizing the splenic flexure of the colon and rotat- ing the descending colon medial, a 10 cm. segment of stomach is mobilized along the greater curvature based on the right gastroepiploic vasculature. Two small gastrostomy incisions are made, and a 16F catheter is inserted and held against the greater curve of the stomach with Babcock clamps. A gastro- intestinal stapling device is used to harvest the tube and the native gastric wall is oversewn with interrupted 3-Zero silk sutures (parts A and B of figure). The harvested gastric segment is tubularized over a 16F catheter in 2 layers of 3-zero polyglycolic acid suture and then submucosally tun- neled 4 cm. through the anterior tenia of the colon just distal

1813

1814 ANTEGRADE CONTINENCE ENEMA FOR FECAL INCONTINENCE IN ADULTS

Patient demographics and results of stomach antegrade continence enema procedure F't. -Age-Sex Diagnosis Prior Urinary Diversion Outcome

SS - 23 - F Myelomeningocele Ileal augment + appendiceal Mitrofanoff Dry

SL - 32 - M Myelomeningocele Ileal conduit, appendectomy Dry, revision for stenosis

RB - 27 - M Myelomeningocele Ileal augment + appendiceal Mitrofanoff Dry KW - 23 - F Myelomeningocele Ileal augment + appendiceal Mitrofanoff Dry PL - 24 - M Myelomeningocele Ileal augment + appendiceal Mitrofanoff Dry

F'G - 54 - F Multiple sclerosis Ileal augment. appendectomy Dry

LG - 52 - F Pelvic pain, sacral rhizotomies Kock pouch, appendectomy Dry

A

Followup (mas.)

34 34 24 24 21 17 3

A, gastrointestinal stapling device is used to harvest 10 cm. gastric segment along greater curvature of stomach based on right gastroepiploic vasculature. B, native gastric wall is oversewn with 3-Zero silk sutures. Harvested gastric segment is tubularized over 16F catheter in 2 layers with %zero polyglycolic acid suture. C, gastric tube is submucosally tunneled through anterior tenia of colon just distal to splenic flexure. Colon is fixed to anterior abdominal wall. T1, gastric tube is brought through rectus muscle over 16F catheter and fixed to fascia of anterior abdominal wall. Stoma is fashioned at level of superficial fascia, and skin is inverted and fixed to fascia to conceal stoma and prevent skin excoriation.

to the splenic flexure (part C of figure). The colon is fixed to the anterior abdominal wall, and the gastric tube is brought through the rectus muscle and secured at the level of the anterior fascia (part D of figure). We believe that submucosal tunneling and colonic fixation to the anterior abdominal wall work in concert to prevent any possibility of reflux. This procedure is not crucial with respect to colonic contents per se but it helps prevent any fluid or mucus from mixing with the gastric mucosa, which might promote increased acid produc- tion. We then mobilize the skin and subcutaneous tissue to

preventing skin excoriation (part D of figure). While a skin level stoma may actually be easier to manage it may lead to skin imtation.

The gastric tube is intubated with a 16F catheter and antegrade irrigations are begun about postoperative day 7. After catheter removal a t 1 week and stoma1 maturity, a catheter is passed and 2 1. warm tap water are run through it while the patient is seated on the toilet. Digital stimulation may be required to initiate bowel emptying and irrigation is continued until clear. Most patients use the antegrade con- tinence enema irrigation every other day.

construct inverted flaps, thus concealing the stoma site and RESULTS

Creation of a nonrefluxing catheterizable gastric tube to the descending colon was successful in all 7 patients. At a mean postoperative followup of 22.4 months (range 3 to 34)

ANTEGRADE CONTINENCE ENEMA FOR FECAL INCONTINENCE IN ADULTS 1815 all patients are continent and use antegrade continence en- ema irrigation every other day on average. Antegrade imga- tion is performed by 5 patients and by attendants for 2 patients. An obese patient required early operative revision 5 weeks postoperatively secondary to stomal stenosis, which was associated with catheter dissection a t the level of the skin between the skin and gastric stoma (see table).

Due to gastric acidity, special followup measures included application of a generic antacid tablet directly to the stoma site and the use of a skin barrier. Physician catheterization of the stoma and conduit was performed a t all postoperative visits to ensure ease of catheterization and absence of objec- tive stenosis. Subjective patient administered question- naires, used for all patients seen at the Emory Continence Center for the last 5 years, were used preoperatively and postoperatively to assess outcome and satisfaction. All pa- tients are satisfied with the outcome to date and none re- quires protective clothing for fecal soiling (see table).

DISCUSSION

Neurogenic bowel is a common sequelae in patients with neurological diseases. Subsequent alterations in bowel func- tion frequently include diarrhea and/or constipation, often leading to fecal incontinence and soiling. Many patients may also have congenital or acquired pelvic floor disorders and significant sensory deficits which exacerbate the situation. Conservative treatment options for such individuals include dietary changes, digital stimulation, rectal suppositories and enemas to initiate colonic emptying. Shandling and Gilmour reported good success with large volume retrograde saline enemas in such ind iv id~als .~ However, some patients are either anatomically unsuitable for this technique or recalci- trant to it, thus providing limited options to those with the worst symptomatic neurogenic bowel.

In 1990 Malone et a1 described a surgical procedure for antegrade colonic washouts through a reversed appendicoce- costomy, termed the antegrade continence enema proce-

This contribution to reconstructive surgery is an out- growth of the Mitrofanoff principle previously described for urological applications.' Many reports have confirmed a high success rate for the antegrade continence enema procedure in patients (mainly children) with neurogenic fecal inconti- n e n ~ e . ~ - l ~ Since its original description variations include in situ imbricateaembedded appendix,8-11, '" in situ unaltered appendix,'" or the use of a continent cecal flap6-'.'" or ta- pered ileum". 13.14 when the appendix was unavailable or unsuitable for use. There is notably limited experience using this procedure in adults.", 12, lF,

It is noteworthy that for all techniques described to date whole colonic irrigation is performed via a catheterizable conduit to the cecum. These patients must usually roll from side to side to produce complete colonic purging, which is more easily accomplished by children and, while entire large bowel irrigation is successful, only the descending colon, sig- moid and rectum are emptied in adults. Thus, we became interested in the application of the stomach as the catheter- izable conduit to the descending colon to reproduce more closely a normal pattern of human defecation. Experience a t our institution using gastric segments as catheterizable con- duits in lower urinary tract reconstruction has been previ- ously described and was deemed favorable in many situa- tions."

We performed video defecography and anorectal manome- try in all cases to ensure that there were no sphincter deficits or abnormalities which might be amenable to surgical sphincteroplasty. Proceeding with the gastric antegrade con- tinence enema procedure in the face of an anatomically ab-

alone suffices to select patients for this procedure. In patients with no prior lower bowel surgery or trauma, in whom all other conservative options (diet, laxatives, retrograde ene- mas) have failed, the antegrade continence enema procedure can be expected to achieve good results.

In our experience gastric tube construction was easily ac- complished and successful. Appendiceal absence or unsuit- ability was noted in all of our patients and further confirmed our initiative to incorporate stomach as the catheterizable conduit for the antegrade continence enema procedure. The proximity of the stomach to the descending colon naturally makes it an attractive alternative for the conduit, especially when the appendix is unavailable, as is frequently the case in adults. In addition, the use of small intestine as the conduit rather than the stomach would require bowel resection and the possibility of its increased morbidity. Concerns of using stomach usually relate to acid production and in our popula- tion the possibility of skin excoriation and ulceration. There- fore, measures to minimize gastric mucosal contact with skin (antirefluxing anastomosis and inverted skin flaps) were taken to obviate these concerns. Although no significant com- plications occurred due to gastric acidity and skin break- down, we prefer to prevent any possible complications rather than treat them once they arise. We now use stomach as our preferred conduit for the antegrade continence enema proce- dure in adults because of its colonic proximity, it obviates the need for bowel resection and it more closely approximates normal adult defecation patterns.

The technique of using the stomach as a conduit to the descending colon evolved as a natural outgrowth in the adult patient to approximate normal defecation patterns more closely, and is especially desirable when the appendix is unavailable or unsuitable. Additional advantages of the gas- tric antegrade continence enema include the possibility of increased fluid intake by colonic absorption in patients who frequently have poor oral fluid intake, and allowing the pa- tient to sit on the toilet and undergo bowel irrigation without having to lay supine and roll from side to side for bowel emptying. Specific stomal care procedures to avoid problems with skin imtation and autodigestion by gastric acid include the application of a generic antacid tablet, crushed and formed into a paste with water, directly on the stoma, liberal use of protective skin barrier and, when needed, systemic (oral) histamine-2 receptor blockers or hydrogen ion pump inhibitors.

CONCLUSIONS

Catheterizable access to the descending colon for the ante- grade continence enema procedure more closely approxi- mates normal defecation patterns by emptying the leR side of the colon. The stomach becomes an attractive option in close proximity for this purpose and is especially advantageous when the appendix is not available for use. The antegrade continence enema procedure can be safely and effectively performed using a gastric segment by reconstructive sur- geons who are familiar with the Mitrofanoff principle.

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1816 ANTEGRADE CONTINENCE ENEMA FOR FECAL INCONTINENCE IN ADULTS

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